1 July
1899.]
INFECTIOUSNESS OF MALARIAL FEVER * AND KALA-AZAR By R. ROSS, M.R.C.S.,
D.P.H.,
by
eveiyone who knows the locality. As Sir W. R. Kinsey, however, said at the discussion of the subject before the Royal Medical and Chirurgical Society [11, p. 820], it is difficult to prove the communicability of diseases which simultaneously affect a number of people. It is proved in thrs case, by the facts everywhere recognised, that Kala-azar tends to confine itself to isolated villages, families and houses, and that it has appeared in such after
frequently
the entry of an affected person. Had the disease spread by the extension of have some meteorological condition, it would it had at spread once; broken out everywhere slowly by means of some morbific influenceexternal extending itself in the elements of families nature, it would not have moved by uniand affected persons. If we accept the think I which on the versal experience subject, that we are bound to do, we must also accept one. the disease is a communicable It is possible that (ordinary) malarial fever is capable of becoming epidemic and of being communicated from the sick to the health}7. What can be said definitely in favour of it ?
things:? Parasites (1) Paludism is a parasitic disease. must propagate themselves; and it would, thereThree
to pass fore, appear to be necessary for them have as from host to host. All parasites which Are the so. studied do yet been sufficiently to be exceptional ? parasites of human malaria Malaria of birds (proteosoma) is commu-
(2)
nicable from sick to healthy sparrows through in this evolution the mosquito. Every step studied under been has necessary to the enquiry have been birds the microscope, and numerous actually infected. Abstracted from
Report, dated 30th
in the similar evolution of one of the human parasites have but the life-history has not
Proteosoma of birds is communicable. Owing great similarity between the avian and
to the
It is generally thought that malarial fever is due to a poison generated in the soil, air, or water of certain localities, thence termed malarious, and that the disease is not commuuicable, directly or indirectly, from the sick to the healthy. On the other hand, Kala-azar, the epidemic communicable fever of Assam, is not connected with any one locality, and it is communicable from the sick to the healthy. Hence, it is said, Kala-azar cannot be malarial fever. The proof that Kala-azar is a spreading disease is, I consider, quite sufficiently established, Brahnamely, that it has actually spread up the Nowthe to Hills the Garo from maputra Valley This fact is attested and District beyond. gong the statements of official statistics and
by
(3) Some steps perhaps two, been made out; been completed. or
_
MAJOR, I.M.8.
*
233
INFECTIOUSNESS OP MALA'RIAL FEVER?ROSS.
jauuary 1899.
human
regard
parasites, and to the fact that research in to the latter has already yielded results
identical to a certain distance with those obtained in respect to the former, it becomes almost impossible to avoid a like conclusion for paludism. In making this statement I do not wish to be misunderstood. The disease cannot be directly communicable like scabies or venereal disease; but rather indirectly like rabies, filariasis, Texas cattle-fever, or nagana. Accepting the analogy with proteosoma, communication will require that the proper species of mosquito, or perhaps other insect, be present, and also that the particular insect has lived for a week or more, after biting the subject, before it can infect the object. Now, mosquitos have many enemies? spiders, bats, strong winds, while, so far as I can ascertain, the species of insect which commonly infest our houses in India, and the larvje of which live in pots of water, garden cisterns, and so on, cannot carry human malaria. Hence it follows that very particular conditions must be present before communication can be established. Such conditions are not likely to exist to any great extent in our hospitals and in the houses of Europeans. In the Nowgong District, however, the houses of the poor are placed in the Situmost favourable situation in this respect. ated on the ground, surrounded by pools of stagnant water, and made generally of open matting work, they permit the ingress of hordes of mosquitos of numerous species which, day and night, bite the half-naked bodies of the inmates, and when gorded, sleep in the dark, damp corners of the roof, returning after digestion for another meal, and living on in the same house probably for weeks and perhaps even months. It will be perceived that a mosquito of the proper species existing in such a situation may carry the infection from any sick person who has entered the house to many of the other inmates in turn; and that, moreover, as suggested in paragraph 30, most of the insects there may shortly become infected and may repeat the dose of malaria nightly to the unfortunate inhabitants until all suffer from a frightful condition of parasitism. Still further, many of the infected insects may escape to neighbouring houses and afflict the occupants of these in a similar manner. Finally, when a patient so attacked removes to another village or hamlet where the mosquitos of the proper species exist, he will start an epidemic of the same nature. The Nature of Kala-azar.?At first it seems to have been assumed that Kcilci-Q/Ziir is
THE INDIAN MEDICAL GAZETTE.
234
the fact of its comand more apparent, more became municability doubt began to be expressed on this head, and the Dr. Giles was directed to investigate matter. He came to the conclusion that the a disease is ankylostomiasis, or rather perhaps mixed anaemia brought about by ankylostomiasis acting on a population worn down by chronic malarial poisoning" [10], and explained the communicability of the disease very satisfactorily by his brilliant researches on the lifehistory of the ankylostomum. For a short period after the publication of Giles's report the medical profession in Assam appear to have accepted his views; by degrees, however, to judge from the literature in the Annual Sanitary Reports, when the profession began to acquire greater familiarity with the disease, and when, especially, Dobson published his paper [15] on the wide prevalence of the ankylostomum among coolies imported into Assam, Giles's conclusions were objected to by many. Accordingly, another medical officer, Captain Rogers, was deputed to reopen the subject. He arrived at the conclusion that Kala-azar is not ankylostomiasis, but malarial fever. His results were, however, questioned by Giles [7], Thornhill [9], and others [8, 14]. To these criticisms he replied at length [12]. It should be mentioned here that Captain Harold Brown has lately reported on a disease called Kala-dulch, now prevalent in the Purnea District of Bengal [10]; and that I have independently become acquainted with a disease in the adjoining Darjeeling District, called in-
malarial; when, however,
"
differently Kala-dulch The facts appear to
or
Kala-jivar.
to be as follows:? Kala-azar is an epidemic and communicable disease. Its symptoms are very like those of mala2. rial fever. In established, i.e., fairly advanced cases, the disease consists principally of considerable enlargement of the spleen and liver, accompanied generally by a low fever, a certain degree of ansemia, and other secondary symptoms. The history of such cases is always that the illness commenced with high fever, generally with repeated rigors; and that the organs began to enlarge after this fever has lasted some time. 3. The death-rate is high; but recovery often occurs. 4. The disease is known to exist only in me
1.
malarious localities.
In Nowgong, Assam side by side with the cases of established Kala-azar, there were numerous cases of typical early malarial fever, in which the malaiial parasites were found in abundance and which already showed commencing and rapidly increasing enlargementofof the liver and a later stage spleen. There were also cases of malarial fever, in which the organs were more enlarged and a few parasites were found; 5.
or
in
[July
1899,
of which, if no parasites could be melanin could be obtained from the
some
detected,
spleen.
6. In cases of established Kalct-azar at Nowgong, the parasites of malaria were found in a few of the more recent ones, and melanin alone in the organs of a few more ; but in many, including some autopsies, no parasites and no melanin at all could be detected. In most of the last, both enlargement of the organs and low fever were present. Yellow pigment was found in a large number of the cases. The 75 cases examined by me (of which details are may be divided into two groups at the four months' limit. There were 42 cases of less than four months' duration ; malarial parasites were found in 26 (6230 of these, while melanin alone was found in three more. There were 33 cases of more than four months' duration ; parasites were found in only four (12%), and melanin alone in ten more. Hence, putting the parasites and melanin together (the latter being as clear evidence of malaria as the former), we find that either one or the other was detected in 69% of the cases of less than four months' duration ; and in 42% of those of more than four months' duration. It is evident that, taking all the cases together, there was an increasing difficulty in finding the parasites as the case? advanced in duration. Out of the total 75 cases, parasites were found in 30 or 40% ; melanin alone in 13, or 17 3% ; and either parasites or melanin in 43, or 57%. Six of the cases were considered to be possibly KalaThese were 18, 19, 20, and 22, all of the same azar. family, of which the first three contained quartan parasites ; also 23, which contained both mild, tertian and sestivo-autumnal parasites; and 27, which contained both black and yellow pigments. Twenty-six of the cases were definitely diagnosed as Kalct-azar?exclusive of the three recovered cases. They were cases 34, 39, 41, 43-43, 54-63 aud 69-75. Parasites were found only in three, namely, 43 (testivoautumnal quotidian), (44 eestivo-autumnal tertian), and 75 (festivo-autumnal). But in the last the parasitic invasion appears to have been an epiphenomenon. Melanin was detected in nine more, namely, 34, 41, 45, 57, 58, 69, 70, 73 and 74. Yellow pigment was found in eleven, namely, 34, 45, 48, 58, 61, 69, 73 and 75 ; occurring alone by itself in 48, 61, 71 and 72. Nothing whatever was found in ten of the cases, namely, 39, 46, 47, 54, 55, 56, 59, 60, 62 and 63 ; but in cases 39, 46 and 60, the blood from the organs was not examined ; while in In all the seven autopnone were autopsies performed. sies on Kala-azar cases either black or yellow pigment
given)
was
observed.
The cases of Kala-azar in which no melanin was detected after what I consider pretty thorough examination, were cases 47 and 56 (spleen only examined); 48, 61 and 62 (both spleen and liver examined) ; and 71 and 72 (autopsies). To these should be added case 75 (autopsy), in which the melanin belonged to a recent parasitic invasion possibly unconnected with the previous morbid condition. Hence we may, I think, conclude that eight out of the 26 Kala-azar cases contained no melanin, or melanin in such small quantities as to be inappreciable. Thus, inclusive of case 75, parasites or melanin were found in twelve of the 26 Kala-azar cases, or in 46%. Neither were found after pretty careful search in seven, Of the remainder, 27%, parasites were found in or 27%. none, but melanin was not exhaustively searched for. Out of the nine Kala-azar in-patients, the eggs of ankylostomes were detected in cases 57, 58, 59, 61, 63 ; and out of the seven Kala-azar autopsies, ankylostomes were found in all but case 75. Thus, the worms were present in 11 out of the 16 cases, or 69%.
July
1899.]
Ill addition I have
INFECTIOUSNESS OF MALARIAL FEVER?ROSS.
already
mentioned that T examined
Terai. 34 cases of sickness at Naxalbari in the Darjeeling I could Of these 14 were said to be cases of Kala-jwar.
between the
-distinguish 110 marked clinical difference which were said to be Kala-jwar cases and 18 of the rest, all alike was examined ordinary fever. The blood of generally only once, as the patients
;
came
to me
mostly
011 two or three occasions. a distance ; but sometimes It is unnecessary to give the cases in detail. They three days to were of varying periods of duration from Parasites were found only in five, or 15 per two years. The forms cent, of them, ar.d only in recent cases. observed were as follows :?Two sestivo-autumnal cases, without crescents, one of three days, and the other of six weeks' duration ; two cases of mild tertian of one or two months' duration, the pigment in the parasites being of three very fine and brown ; one case of quartan, months' duration. ones These cases were practically the most recent had a examined ; 011I3- one of tlieni (a tertian case) the ribs. spleen enlarged more than an inch or so below and I11 the older cases the organs were more enlarged, 110 parasites were observed. No crescents at all were seen, which is just the opposite of Brown's experience with Kala-dukh. The hepatic and splenic bloods were not examined. of The motions were studied when procurable, and ova as found, and ankylostomes round-worms, whip-worms usual, in a certain percentage. those exin The cases were similar every respect to was amined at Nowgong, except, perhaps, that the liver few not so much affected They were also similar to a Dr. and cases of Kala-azar shown to me by Dr. Lavertine
from
Price near Nowgong. last I have studied the parasites of malaria during the Sefour years in many parts of this country ; especially cunderabad, Bangalore, theSigur Grhat near Ootacamund, Khervvara in Rajputana, the Darjeeling Terai. and Nowand gon
1899.]
INFECTIOUSNESS OF MALARIAL FEVER * AND KALA-AZAR By R. ROSS, M.R.C.S.,
D.P.H.,
by
eveiyone who knows the locality. As Sir W. R. Kinsey, however, said at the discussion of the subject before the Royal Medical and Chirurgical Society [11, p. 820], it is difficult to prove the communicability of diseases which simultaneously affect a number of people. It is proved in thrs case, by the facts everywhere recognised, that Kala-azar tends to confine itself to isolated villages, families and houses, and that it has appeared in such after
frequently
the entry of an affected person. Had the disease spread by the extension of have some meteorological condition, it would it had at spread once; broken out everywhere slowly by means of some morbific influenceexternal extending itself in the elements of families nature, it would not have moved by uniand affected persons. If we accept the think I which on the versal experience subject, that we are bound to do, we must also accept one. the disease is a communicable It is possible that (ordinary) malarial fever is capable of becoming epidemic and of being communicated from the sick to the health}7. What can be said definitely in favour of it ?
things:? Parasites (1) Paludism is a parasitic disease. must propagate themselves; and it would, thereThree
to pass fore, appear to be necessary for them have as from host to host. All parasites which Are the so. studied do yet been sufficiently to be exceptional ? parasites of human malaria Malaria of birds (proteosoma) is commu-
(2)
nicable from sick to healthy sparrows through in this evolution the mosquito. Every step studied under been has necessary to the enquiry have been birds the microscope, and numerous actually infected. Abstracted from
Report, dated 30th
in the similar evolution of one of the human parasites have but the life-history has not
Proteosoma of birds is communicable. Owing great similarity between the avian and
to the
It is generally thought that malarial fever is due to a poison generated in the soil, air, or water of certain localities, thence termed malarious, and that the disease is not commuuicable, directly or indirectly, from the sick to the healthy. On the other hand, Kala-azar, the epidemic communicable fever of Assam, is not connected with any one locality, and it is communicable from the sick to the healthy. Hence, it is said, Kala-azar cannot be malarial fever. The proof that Kala-azar is a spreading disease is, I consider, quite sufficiently established, Brahnamely, that it has actually spread up the Nowthe to Hills the Garo from maputra Valley This fact is attested and District beyond. gong the statements of official statistics and
by
(3) Some steps perhaps two, been made out; been completed. or
_
MAJOR, I.M.8.
*
233
INFECTIOUSNESS OP MALA'RIAL FEVER?ROSS.
jauuary 1899.
human
regard
parasites, and to the fact that research in to the latter has already yielded results
identical to a certain distance with those obtained in respect to the former, it becomes almost impossible to avoid a like conclusion for paludism. In making this statement I do not wish to be misunderstood. The disease cannot be directly communicable like scabies or venereal disease; but rather indirectly like rabies, filariasis, Texas cattle-fever, or nagana. Accepting the analogy with proteosoma, communication will require that the proper species of mosquito, or perhaps other insect, be present, and also that the particular insect has lived for a week or more, after biting the subject, before it can infect the object. Now, mosquitos have many enemies? spiders, bats, strong winds, while, so far as I can ascertain, the species of insect which commonly infest our houses in India, and the larvje of which live in pots of water, garden cisterns, and so on, cannot carry human malaria. Hence it follows that very particular conditions must be present before communication can be established. Such conditions are not likely to exist to any great extent in our hospitals and in the houses of Europeans. In the Nowgong District, however, the houses of the poor are placed in the Situmost favourable situation in this respect. ated on the ground, surrounded by pools of stagnant water, and made generally of open matting work, they permit the ingress of hordes of mosquitos of numerous species which, day and night, bite the half-naked bodies of the inmates, and when gorded, sleep in the dark, damp corners of the roof, returning after digestion for another meal, and living on in the same house probably for weeks and perhaps even months. It will be perceived that a mosquito of the proper species existing in such a situation may carry the infection from any sick person who has entered the house to many of the other inmates in turn; and that, moreover, as suggested in paragraph 30, most of the insects there may shortly become infected and may repeat the dose of malaria nightly to the unfortunate inhabitants until all suffer from a frightful condition of parasitism. Still further, many of the infected insects may escape to neighbouring houses and afflict the occupants of these in a similar manner. Finally, when a patient so attacked removes to another village or hamlet where the mosquitos of the proper species exist, he will start an epidemic of the same nature. The Nature of Kala-azar.?At first it seems to have been assumed that Kcilci-Q/Ziir is
THE INDIAN MEDICAL GAZETTE.
234
the fact of its comand more apparent, more became municability doubt began to be expressed on this head, and the Dr. Giles was directed to investigate matter. He came to the conclusion that the a disease is ankylostomiasis, or rather perhaps mixed anaemia brought about by ankylostomiasis acting on a population worn down by chronic malarial poisoning" [10], and explained the communicability of the disease very satisfactorily by his brilliant researches on the lifehistory of the ankylostomum. For a short period after the publication of Giles's report the medical profession in Assam appear to have accepted his views; by degrees, however, to judge from the literature in the Annual Sanitary Reports, when the profession began to acquire greater familiarity with the disease, and when, especially, Dobson published his paper [15] on the wide prevalence of the ankylostomum among coolies imported into Assam, Giles's conclusions were objected to by many. Accordingly, another medical officer, Captain Rogers, was deputed to reopen the subject. He arrived at the conclusion that Kala-azar is not ankylostomiasis, but malarial fever. His results were, however, questioned by Giles [7], Thornhill [9], and others [8, 14]. To these criticisms he replied at length [12]. It should be mentioned here that Captain Harold Brown has lately reported on a disease called Kala-dulch, now prevalent in the Purnea District of Bengal [10]; and that I have independently become acquainted with a disease in the adjoining Darjeeling District, called in-
malarial; when, however,
"
differently Kala-dulch The facts appear to
or
Kala-jivar.
to be as follows:? Kala-azar is an epidemic and communicable disease. Its symptoms are very like those of mala2. rial fever. In established, i.e., fairly advanced cases, the disease consists principally of considerable enlargement of the spleen and liver, accompanied generally by a low fever, a certain degree of ansemia, and other secondary symptoms. The history of such cases is always that the illness commenced with high fever, generally with repeated rigors; and that the organs began to enlarge after this fever has lasted some time. 3. The death-rate is high; but recovery often occurs. 4. The disease is known to exist only in me
1.
malarious localities.
In Nowgong, Assam side by side with the cases of established Kala-azar, there were numerous cases of typical early malarial fever, in which the malaiial parasites were found in abundance and which already showed commencing and rapidly increasing enlargementofof the liver and a later stage spleen. There were also cases of malarial fever, in which the organs were more enlarged and a few parasites were found; 5.
or
in
[July
1899,
of which, if no parasites could be melanin could be obtained from the
some
detected,
spleen.
6. In cases of established Kalct-azar at Nowgong, the parasites of malaria were found in a few of the more recent ones, and melanin alone in the organs of a few more ; but in many, including some autopsies, no parasites and no melanin at all could be detected. In most of the last, both enlargement of the organs and low fever were present. Yellow pigment was found in a large number of the cases. The 75 cases examined by me (of which details are may be divided into two groups at the four months' limit. There were 42 cases of less than four months' duration ; malarial parasites were found in 26 (6230 of these, while melanin alone was found in three more. There were 33 cases of more than four months' duration ; parasites were found in only four (12%), and melanin alone in ten more. Hence, putting the parasites and melanin together (the latter being as clear evidence of malaria as the former), we find that either one or the other was detected in 69% of the cases of less than four months' duration ; and in 42% of those of more than four months' duration. It is evident that, taking all the cases together, there was an increasing difficulty in finding the parasites as the case? advanced in duration. Out of the total 75 cases, parasites were found in 30 or 40% ; melanin alone in 13, or 17 3% ; and either parasites or melanin in 43, or 57%. Six of the cases were considered to be possibly KalaThese were 18, 19, 20, and 22, all of the same azar. family, of which the first three contained quartan parasites ; also 23, which contained both mild, tertian and sestivo-autumnal parasites; and 27, which contained both black and yellow pigments. Twenty-six of the cases were definitely diagnosed as Kalct-azar?exclusive of the three recovered cases. They were cases 34, 39, 41, 43-43, 54-63 aud 69-75. Parasites were found only in three, namely, 43 (testivoautumnal quotidian), (44 eestivo-autumnal tertian), and 75 (festivo-autumnal). But in the last the parasitic invasion appears to have been an epiphenomenon. Melanin was detected in nine more, namely, 34, 41, 45, 57, 58, 69, 70, 73 and 74. Yellow pigment was found in eleven, namely, 34, 45, 48, 58, 61, 69, 73 and 75 ; occurring alone by itself in 48, 61, 71 and 72. Nothing whatever was found in ten of the cases, namely, 39, 46, 47, 54, 55, 56, 59, 60, 62 and 63 ; but in cases 39, 46 and 60, the blood from the organs was not examined ; while in In all the seven autopnone were autopsies performed. sies on Kala-azar cases either black or yellow pigment
given)
was
observed.
The cases of Kala-azar in which no melanin was detected after what I consider pretty thorough examination, were cases 47 and 56 (spleen only examined); 48, 61 and 62 (both spleen and liver examined) ; and 71 and 72 (autopsies). To these should be added case 75 (autopsy), in which the melanin belonged to a recent parasitic invasion possibly unconnected with the previous morbid condition. Hence we may, I think, conclude that eight out of the 26 Kala-azar cases contained no melanin, or melanin in such small quantities as to be inappreciable. Thus, inclusive of case 75, parasites or melanin were found in twelve of the 26 Kala-azar cases, or in 46%. Neither were found after pretty careful search in seven, Of the remainder, 27%, parasites were found in or 27%. none, but melanin was not exhaustively searched for. Out of the nine Kala-azar in-patients, the eggs of ankylostomes were detected in cases 57, 58, 59, 61, 63 ; and out of the seven Kala-azar autopsies, ankylostomes were found in all but case 75. Thus, the worms were present in 11 out of the 16 cases, or 69%.
July
1899.]
Ill addition I have
INFECTIOUSNESS OF MALARIAL FEVER?ROSS.
already
mentioned that T examined
Terai. 34 cases of sickness at Naxalbari in the Darjeeling I could Of these 14 were said to be cases of Kala-jwar.
between the
-distinguish 110 marked clinical difference which were said to be Kala-jwar cases and 18 of the rest, all alike was examined ordinary fever. The blood of generally only once, as the patients
;
came
to me
mostly
011 two or three occasions. a distance ; but sometimes It is unnecessary to give the cases in detail. They three days to were of varying periods of duration from Parasites were found only in five, or 15 per two years. The forms cent, of them, ar.d only in recent cases. observed were as follows :?Two sestivo-autumnal cases, without crescents, one of three days, and the other of six weeks' duration ; two cases of mild tertian of one or two months' duration, the pigment in the parasites being of three very fine and brown ; one case of quartan, months' duration. ones These cases were practically the most recent had a examined ; 011I3- one of tlieni (a tertian case) the ribs. spleen enlarged more than an inch or so below and I11 the older cases the organs were more enlarged, 110 parasites were observed. No crescents at all were seen, which is just the opposite of Brown's experience with Kala-dukh. The hepatic and splenic bloods were not examined. of The motions were studied when procurable, and ova as found, and ankylostomes round-worms, whip-worms usual, in a certain percentage. those exin The cases were similar every respect to was amined at Nowgong, except, perhaps, that the liver few not so much affected They were also similar to a Dr. and cases of Kala-azar shown to me by Dr. Lavertine
from
Price near Nowgong. last I have studied the parasites of malaria during the Sefour years in many parts of this country ; especially cunderabad, Bangalore, theSigur Grhat near Ootacamund, Khervvara in Rajputana, the Darjeeling Terai. and Nowand gon
